Not all ST-segment changes are myocardial injury: hypercalcaemia-induced ST-segment elevation

Abstract

ST-segment elevation myocardial infarction is an important, life-threatening diagnosis that requires quick diagnosis and management. We describe the case of an 83-year-old man with coronary artery disease, ischaemic cardiomyopathy with left ventricular ejection fraction of 15%, newly diagnosed multiple myeloma that had an initial ECG showing ST-segment elevation in anterior leads V1-3 and ST-segment depression in lateral leads concerning for an ST-segment elevation myocardial infarction. Troponins were negative and his calcium was 3.55 mmol/L. It was thought that the ECG changes were not indicative of cardiac ischaemia but, rather, hypercalcaemia. He was treated with fluids, diuretics and zolendronic acid, with subsequent resolution of ST-segment changes. This case demonstrates that one must consider disease other than myocardial ischaemia as the culprit of ST-segment changes if physical examination and history do not point towards myocardial injury, as unnecessary invasive revascularisation procedures have inherent risks.

Hypercalcemia-Induced ST-Segment Elevation Mimicking Acute Myocardial Injury: A Case Report and Review of the Literature

“…e striking EKG finding seen in our patient was the presence of diffuse ST-segment elevation mimicking acute coronary syndrome. While such a finding was previously reported in the literature, mostly in case reports, in this case, we were able to trend and correlate the EKG findings from initial diagnosis till resolution of ST changes by measuring calcium levels and repeating EKGs at serial intervals [4][5][6][7]. While this patient's EKG demonstrated diffuse elevations, it also demonstrated concomitant short QT interval with a notchshaped T wave trait more commonly associated with hypercalcemia.…”

“…Other possibilities include development of a biphasic or flattened T wave that mimics an ST-segment elevation. In addition, the altered equilibrium of ionic flow across the potassium and calcium channels can also lead to such ST-segment changes [5]. Other differentials to be considered for evaluation of STsegment elevation in absence of ACS include early repolarization, pericarditis, hypertrophic cardiomyopathy, increased intra cranial pressure, and Brugada syndrome ( Table 1).…”

Rare ST-Elevation Myocardial Infarction Mimic: Diabetic Ketoacidosis With Severe Hypercalcemia

“…The most commonly described ECG change of hypercalcemia is a shortened QTc interval due to rapid repolarization. However, severely elevated calcium levels have been reported to mimic ST-elevation on the ECG [8,9]. Some other ECG changes expected may include abrupt upslope of T wave, PR interval prolongation, and increase the amplitude of the QRS complex.…”

24-hour outpatient ECG as a screening method in patients with primary hyperparathyroidism

“…Moreover, T waves may fl atten or invert, and a variable degree of heart block may develop (7,8). Shawn et al described the case of a patient with ST segment elevation induced by hypercalcemia (9,10). Hypercalcemia can also cause an ECG fi nding mimicking hypothermia, known as an Osborn wave (11).…”